Provider Demographics
NPI:1952009664
Name:BULLOCK, WELDON III
Entity Type:Individual
Prefix:
First Name:WELDON
Middle Name:
Last Name:BULLOCK
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8392 SIX FORKS RD STE 201
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3061
Mailing Address - Country:US
Mailing Address - Phone:984-222-3006
Mailing Address - Fax:
Practice Address - Street 1:537 ASHGREEN CT
Practice Address - Street 2:
Practice Address - City:ROLESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27571-9217
Practice Address - Country:US
Practice Address - Phone:919-999-7445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0184541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical